Dear Ben,
Some of the references you gave do not say what you may think they say.
I am only familiar with the papers on traumatic brain injury, and will
have to look up the other references.
As far as the TBI papers (Davis, Wang) are concerned, these compared
patients who had been intubated in the field with those who had not. The
patients who were intubated fell into two different groups: in most
patients intubation was done without anesthesia, in few patients
(aeromedical teams) it was done with anesthesia (or at least the use of
relaxants). All three papers found that intubated patients had a
significantly higher mortality. They used logistic regression to correct
for cofounding factors (age, ISS, GCS, etc.). All three papers describe
a subgroup of patients where no difference in mortality (or even a
beneficial effect of intubation) was found: it was the group of patients
where anesthesia or relaxants were used.
It is obvious that patients who tolerate endotracheal intubation without
anesthesia or relaxants are different from patients who do not need
intubation, or who will not tolerate it without anesthesia or relaxants,
even if logistic regression will correct for all other significant
factors. The intubated patients in these studies were more seriously
injured, and that explains the difference in mortality. And if you
compare the mortality rates for the intubated patients (49% and 55%!) it
is clear that this were patients who were most severely injured; the
"standard" mortality for patients with severe TBI (GCS <9) is somewhere
between 30 and 35%; at least, that are the rates published by other
groups.
It is also telling that there was no deleterious effect of intubation in
the patients who were treated by aeromedical teams; they can freely
decide whether to intubate or not, because they can use drugs whenever
they are required.
To conclude, at present there is no evidence that endotracheal
intubation in the field worsens outcome. The studies published so far
are all retrospective, and are biased because the intubated patients
were more seriously injured than those that were not intubated. It would
need a prospective study done in a system where drugs may be used to
facilitate intubation to answer that question convincingly.
One question, however, remains: is intubation really the "gold
standard"? There are so many other effective means to secure the airway
that are easier to learn and to teach.
with best regards
Walter Mauritz MD PhD
Professor of Anesthesia and Critical Care Medicine
Trauma Hospital "Lorenz Boehler"
A - 1200 Vienna, AUSTRIA, EU
phone: ++43 1 33110 789
fax: ++43 1 33110 277
e-mail: walter.mauritz at auva.at
-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Ben Reynolds
Sent: Thursday, April 06, 2006 5:44 PM
To: Trauma &amp, Critical Care mailing list; Melissa Markey
Subject: Re: Re: Rescue Airway Techniques
There is an evolving body of literature which argues
exactly the OPPOSITE, that in fact prehospital
intubation as an independent event in severe head
injury*, hypovolemic shock** AND in pediatric
patients*** is associated with HIGHER morbidity and
mortality.
Ben Reynolds, PA-C
Pittsburgh, PA
*Bochicchio GV, Ilahi O, Joshi M, Bochicchio K, Scalea
TM. Endotracheal intubation in the field does not
improve outcome in trauma patients who present without
an acutely lethal traumatic brain injury. J Trauma.
2003 Feb;54(2):307-11.
*Davis DP, Peay J, Sise MJ, Vilke GM, Kennedy F,
Eastman AB, Velky T, Hoyt DB. The impact of
prehospital endotracheal intubation on outcome in
moderate to severe traumatic brain injury. J Trauma.
2005 May;58(5):933-9.
*Sen A, Nichani R. Best evidence topic report.
Prehospital endotracheal intubation in adult major
trauma patients with head injury. Emerg Med J. 2005
Dec;22(12):887-9.
*Wang HE, Peitzman AB, Cassidy LD, Adelson PD, Yealy
DM. Out-of-hospital endotracheal intubation and
outcome after traumatic brain injury. Ann Emerg Med.
2004 Nov;44(5):439-50.
*Davis DP, Stern J, Sise MJ, Hoyt DB. A follow-up
analysis of factors associated with head-injury
mortality after paramedic rapid sequence intubation. J
Trauma. 2005 Aug;59(2):486-90.
**Shafi S, Gentilello L. Pre-hospital endotracheal
intubation and positive pressure ventilation is
associated with hypotension and decreased survival in
hypovolemic trauma patients: an analysis of the
National Trauma Data Bank. J Trauma. 2005
Nov;59(5):1140-5; discussion 1145-7.
***DiRusso SM, Sullivan T, Risucci D, Nealon P, Slim
M. Intubation of pediatric trauma patients in the
field: predictor of negative outcome despite risk
stratification. J Trauma. 2005 Jul;59(1):84-90;
discussion 90-1.
--- stefmazur at ausdoctors.net wrote:
> Melissa,
>> What is the evidence that shows having an ET tube
> placed pre-hospital saves these patients
> "significant mortality and morbidity"?
>> My reading (admittedly limited) seems to suggest the
> opposite, so would be interested in what evidence
> has lead you to your conclusion.
>> Cheers,
> Stefan Mazur
> Emergency Physician
>> >With all due respect, I have a different suggestion
> - how about
> >anesthetists and anesthesiologists willingly
> sharing their knowledge and
> >giving paramedics more chances to practice
> intubation in a controlled
> >setting (i.e., consider us as important to train as
> you do residents,
> >and stop giving the residents all the tubes). Last
> time I was in the OR
> >for ET practice, I got 0 chances out of an 8 hour
> day. Why? Because
> >anesthesia always found a reason to say no - No,
> this patient has caps
> >on her teeth. No, this patient is in for elective
> surgery. No, we want
> >the resident to get some experience. Not a very
> effective investment of
> >my time. And not a very appropriate way to behave,
> to my thinking.
> >
> >Experienced paramedics can intubate quite
> successfully - and quickly.
> >The determining factor is not whether you have an
> MD or other degree -
> >it is the experience. Experience in controlled
> settings helps you
> >anticipate the problems in the uncontrolled
> environment - and helps you
> >understand when you will be able to get the tube,
> and when you just
> >secure whatever airway you can get and run.
> >
> >Patients may or may not have already aspirated -
> often they haven't,
> >and the reason they aspirate is because someone is
> thumping and pumping
> >on them. Having an ET in place saves these
> patients significant
> >morbidity and mortality - and isn't that what this
> EMS is all about???
> >No, paramedics shouldn't spend 10 minutes on the
> scene trying to get an
> >ET tube in. That is not the same thing as saying
> that ET in the field
> >is inappropriate. If you can get a tube quickly,
> without undue
> >deprivation of oxygen, do it. If you can't,
> acknowledge you are human,
> >use an alternative, and get the patient to
> definitive care.
> >
> >The debate about ET in the field is really a
> question of ensuring
> >appropriate training and experience. There are
> lots of medics out there
> >who would be very happy to have more experience in
> controlled settings.
> >Any anesthetists/anesthesiologists willing to
> help???
> >
> >P.S. If you prohibit pre-hospital intubation
> absent hundreds of
> >intubations (in what time period?), don't forget
> that residents in the
> >EMS fellowships and flight nurses, etc. won't be
> able to tube either,
> >until they get that many tubes. In that case,
> paramedics should have
> >the chance to accomplish the same criteria, and we
> are back where I
> >started - it all comes down to providing
> opportunities for experience.
> >
> >My .02 worth
> >Melissa
> >
> >>>> SeppelI at wahs.nsw.gov.au 4/5/2006 8:52:48 PM >>>
> >What say the anaesthetists? Speaking as both an
> anaesthetist and an
> >intensivist, I have no problem with what you are
> saying in principle,
> >but we are discussing totally different things.
> >
> >I use nasotracheal tubes in appropriate patients
> (the risk of
> >sinusitis
> >is often grossly overstated). I have done digital
> intubation as well,
> >but that is not something to recommend to an
> inexperienced operator
> >and
> >not a situation I want to be in again. Your key
> word is "- with
> >experience". With the right experience you can do
> anything you like,
> >but
> >for the majority of people out there with less
> experience what you
> >propose is pretty impractical, whereas there is a
> lot of data out
> >there
> >that the LMA is readily inserted to provide a
> relaible airway by even
> >the most inexperienced people with a minimum
> training. And it's pretty
> >good for experienced people too, while your heart
> rate comes down, the
> >patient's heart rate comes back up, and you think
> of your next option.
> >
> >Nobody has ever called an LMA a "definitive airway"
> per the ATLS
> >definition of "piece of cuffed plastic in the
> trachea". What we are
> >talking about is 'rescue technique of choice for
> failed intubation'.
> >And
> >in that context aspiration is irrelevant - I'll
> deal with the
> >aspiration
> >later in the ICU, and most of these patients have
> aspirated anyway,
> >prior to attempts to intubate.
> >
> >A whole different question, which Ken Harrison
> raised, is whether 'non
> >experts' (and by that I mean the experience of
> HUNDREDS of in hospital
> >intubations first including a fair number of
> difficult ones) should
> >even
> >be attempting to intubate pre hospital, as opposed
> to simple airway
> >manouvres and driving fast. The data just isn't
> there at present to
> >support prehospital intubation, and things like the
> Los Angeles study
> >show that by trying to intubate you waste a lot of
> time without doing
> >anything to improve outcomes.
> >
> >Food for thought, isn't it?
> >
> >Cheers, Ian
> >
> >Ian Seppelt FANZCA FJFICM
> >Staff Specialist in Intensive Care Medicine
> >The Nepean Hospital,
> >PO Box 63, Penrith NSW 2751
> >Clinical Lecturer, University of Sydney
> >
> >
> >>>> bensonblues at comcast.net 6/04/2006 3:38am >>>
> >As a wayward Yankee ER doc, I've been enlightened
> by the LMA
> >discussion. Haven't used one, but I know they're
> used in the OR for
> >short cases, dificult intubations, etc. But, they
> can't be considered
> >definitive (do not secure the airway against
> aspiration). In my
> >training
> >at Detroit Receiving Hospital (ca 1980's) almost
> all of the trauma
> >patients requiring intubation in the ED received
> nasotracheal tubes
> >(NTI). Archaic, eh? But, we were good at it, and
> rarely was NTI
> >unsuccessful in the spontaneously breathing patient
> (ketamine being an
> >excellent agent to facilitate the procedure, and
> use a 6.5 - 7.5
> >cuffed
> >tube). Even in the apneic pt, NTI can be quite
> successful and fairly
> >easy to perform - with experience. I still use NTI
> in dificult
> >airways,
> >and "rescued" one apneic fellow with no neck just
> the other day (the
> >intensivists groan, because of risk of sinusitis).
> Another technique
> >is
> >digital - by placing your 2nd and 3rd fingers in
> the hypopharynx volar
> >side up, I have also been able to guide the tube
> into
=== message truncated ===
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